RIRDC Rural Women's Award Entry Form

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Entry Form
Selection Criteria & How to Enter
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For further information contact:
Edwina Clowes,
RIRDC Rural Women's Award National Coordinator.
Mobile: 0417 727 544
clowesedwina@bigpond.com

Entry Form for The Australian RIRDC Rural Women's Award 2012

There are four ways you can submit your entry for the Rural Women's Award 2012

1. RWA 2012 Online Entry form

2. PDF download - you can download the Application Brochure and Entry Form as pdf files. (If you need the free version of Acrobat Reader click here.)

3. RWA 2012 Entry Form as html (You can print this html page for your application )

4. RWA Entry Form in Word

Applicant's Name AND Preferred Title:	Applicant's Address:
Applicant's Home Phone Number:	Applicant's Email Address:
Applicant's Work Phone Number:	Applicant's Mobile Phone Number:
Name of 1st Referee & Relationship to Applicant:	Name of 2nd Referee & Relationship to Applicant:
1st Referee's Address:	2nd Referee's Address
1st Referee's Work Phone Number:	2nd Referee's Work Phone:
1st Referee's Home Phone Number:	2nd Referee's Home Phone:
1st Referee's Mobile Phone Number:	2nd Referee's Mobile Number:
1st Referee's Email Address:	2nd Referee's Email Address:
Brief Summary of Proposed Activity:

Nominated by (if applicable)

___________________________________________________

I (the entrant) acknowledge agreement to the terms and conditions of entry, and commit that none of my past actions will cause embarrassment to, or bring the award and relevant agencies into disrepute.

Signature:

........................................................................

Name (please print)

.......................................................................................

Date: ...................../................../2011

Copyright Release
As a consideration of my entry into this Award I grant the Rural Industries Research and Development Corporation (RIRDC) and the state/territory departments of agriculture/primary industries the 'non-exclusive' rights to publish material generated from my involvement in the Award and from the outcomes of the Bursary.